What is Autoimmune Hepatitis and Pregnancy?
Autoimmune hepatitis (AIH) is a long-term liver condition typically associated with certain antibodies in the blood and high levels of a protein called globulin. This ongoing inflammation in the liver’s cells isn’t related to other common causes of chronic liver disease, like alcohol-related liver disease, viral hepatitis, genetic liver disorders, or exposure to harmful substances. Over time, AIH can evolve from an acute hepatitis to a chronic liver disease and eventually lead to a severe condition called cirrhosis. It is not a common disorder, affecting only about one in every 100,000 in the general population. It’s more common in women, usually those of childbearing age, but it can happen at any age.
Being diagnosed with AIH and having certain antibodies can increase the risk of complications during pregnancy and the period immediately after birth. There’s not a lot of data on the outcomes of pregnancies in women with AIH as there are only a few studies available. However, due to improvements in healthcare, there’s a rise in reported pregnancies among these patients. At present, with top-quality prenatal and postnatal care, pregnancy and childbirth seem to be safe for women with AIH and their babies. We aim to share knowledge on how to diagnose and manage AIH during pregnancy in this article.
What Causes Autoimmune Hepatitis and Pregnancy?
Autoimmune hepatitis – in pregnant women or otherwise – is currently thought to be caused by something from the environment acting on a person who’s naturally more susceptible because of their genes. It’s not exactly understood how the genes and this autoimmune process are connected, but researchers think that it involves a substance known as an antigen, a major histocompatibility complex (MHC), and a T-cell receptor. These three things come together and form a kind of complex where the antigen-MHC complex is recognized and contacted.
The environmental factors that could potentially trigger this T cell-based immune response, which targets the liver, are thought to be things like viruses, certain medications, herbal supplements, and even vaccines. However, in most cases, the exact cause of the autoimmunity is never found.
Risk Factors and Frequency for Autoimmune Hepatitis and Pregnancy
Autoimmune hepatitis is a condition that doesn’t occur very often, with about 1 case per 100,000 people. It is most common in women, particularly during their childbearing years, but people of any age can have their first episode of this disease.
- The disease is seen more often in women.
- Usually, it develops during a woman’s childbearing years.
- However, the first episode can occur at any age.
The disease displays different patterns based on its type. In Type 1 autoimmune hepatitis, there are four times as many female patients as male patients. In Type 2, this difference is even more prominent, with ten times as many women affected as men.
- For Type 1 autoimmune hepatitis, there are four times as many women as men affected.
- For Type 2 autoimmune hepatitis, the ratio increases to ten women for every man.
Signs and Symptoms of Autoimmune Hepatitis and Pregnancy
Autoimmune hepatitis is a disease that can show up in many ways. Sometimes it shows as an acute or chronic disease, or it can sometimes be found out unexpectedly through regular health tests for things like insurance, employment, or blood donation. People with this disease often feel tired, lose their appetite, have unexplained weight loss, and even liver failure which shows up as yellowing of the skin (jaundice), build-up of fluid in the abdomen (ascites), or blood clotting issues (coagulopathy).
In both pregnant women and others, the signs of autoimmune hepatitis can range from no physical signs at all to signs that suggest liver disease or failure like jaundice, ascites, and enlarged spleen (splenomegaly).
People with autoimmune hepatitis might also have another autoimmune disease at the same time. The most common ones found along with autoimmune hepatitis are:
- Autoimmune thyroiditis
- Rheumatoid arthritis
- Systemic lupus erythematosus
- Type 1 diabetes mellitus
- Celiac disease
- Ulcerative colitis
Testing for Autoimmune Hepatitis and Pregnancy
Diagnosing autoimmune hepatitis, a condition where the body’s immune system attacks the liver, is the same for pregnant women and everyone else. This diagnosis is usually based on certain patterns seen in blood tests and tissue samples together with ruling out other kinds of chronic liver disease. Sometimes, the condition can be recognized based on symptoms and lab results, so a liver biopsy, where a small sample of liver tissue is taken for examination, isn’t always necessary.
If your symptoms and lab results hint toward autoimmune hepatitis, it’s recommended to run blood tests for certain antibodies. These include ANA, ASMA, AMA, and ALKM-1 antibodies, along with either IgG (a type of protein the immune system uses to fight infections) or gamma globulin level. If these antibodies aren’t found in your blood, other specific tests can be ordered.
Autoimmune hepatitis comes in two main types, categorized by the type of autoantibodies, or proteins produced by the immune system that mistakenly fight the body’s own cells:
- Type 1 AIH: This usually involves ANA and/or ASMA antibodies with F-actin specificity.
- Type 2 AIH: This typically involves ALKM-1 and/or ALC-1 antibodies.
About one in five people who show signs of autoimmune hepatitis don’t have the typical antibodies in their bloodstream. Often, these people are diagnosed with autoimmune hepatitis only when they respond well to anti-inflammatory therapy.
In certain cases, if autoimmune hepatitis is suspected, a liver biopsy might be needed. This can help confirm the diagnosis and guide treatment, especially for those with few or unusual symptoms, negative antibody tests, or normal IgG levels. After the biopsy, the diagnosis is confirmed based on the characteristics of the liver tissue sample.
Treatment Options for Autoimmune Hepatitis and Pregnancy
The impact of autoimmune hepatitis (AIH) on pregnancy can be unpredictable. Research suggests as many as one in five patients with this condition may experience a flare-up during pregnancy, which can lead to complications for both the mother and baby. Because of this, it’s generally recommended that women with AIH postpone getting pregnant until their disease is well-managed.
When it comes to medical treatment during pregnancy, the preferred approach includes glucocorticoids, which are a type of steroid, and may be used alone or in combination with azathioprine, a type of medicine used to suppress the immune system. Although use of these drugs during pregnancy carries some risk, they have not been found to greatly increase the likelihood of harmful outcomes for the mother or baby. As a result, keeping AIH under control is thought to outweigh these risks, and treatment is recommended to continue throughout pregnancy, with close monitoring for flare-ups. However, other treatments for AIH, like mycophenolate mofetil (MMF) and tacrolimus, are not recommended during pregnancy due to the risk of congenital malformations and other serious problems.
While breastfeeding, prednisone is considered safe. Similarly, azathioprine is found at low levels in breast milk and is mostly considered safe for continued use, in spite of manufacturer’s recommendations. There’s no available data on the safety of budesonide and mycophenolate during breastfeeding.
If a woman with AIH has a flare-up during pregnancy, treatment is usually similar to that for non-pregnant patients – consisting of higher doses of prednisone and possibly the addition of azathioprine.
It is notable that liver cirrhosis, a serious liver condition, can occur in up to 40% of patients at the time of AIH diagnosis. Pregnant women with cirrhosis due to AIH face increased risks, so comprehensive discussions with medical specialists regarding options like surrogate pregnancy, terminating the pregnancy or delaying pregnancy until after a liver transplant are necessary.
Pregnant women with cirrhosis may also be at risk of the expansion of certain veins which can lead to increased pressure in the portal vein causing a potential risk of bleeding. To manage this, it’s recommended that these patients undergo an endoscopy around their 28th week of pregnancy to identify and potentially treat high-risk varices.
After delivery, patients with AIH may experience more frequent flare-ups than during pregnancy. It’s recommended that these patients have regular follow-ups with liver specialists postpartum and get tested for liver function and immunoglobulin G (a type of antibody) levels at delivery and again at 4 to 6 week intervals for the first three months after giving birth.
What else can Autoimmune Hepatitis and Pregnancy be?
Autoimmune hepatitis can appear in many different ways in patients. It’s often considered when patients show unusual liver test results, cirrhosis, sudden hepatitis or sudden liver failure. However, diagnosing this condition can be challenging because it can show up differently in different people. This includes instances where AIH doesn’t produce the expected antibodies, is caused by medication, shares traits with other liver diseases such as primary biliary cirrhosis (PBC) or primary sclerosing cholangitis (PSC), or even occurs unexpectedly after a liver transplant.
What to expect with Autoimmune Hepatitis and Pregnancy
Autoimmune hepatitis (AIH) can lead to an increased risk of complications during pregnancy for both the mother and the baby. Despite these concerns, evidence shows that pregnancies amongst women with AIH are becoming more common. This is due to improved medical care and higher quality prenatal and antenatal services. With the current standard of care, it appears that pregnancy and childbirth are generally safe for women with AIH and their babies.
Possible Complications When Diagnosed with Autoimmune Hepatitis and Pregnancy
Pregnant women who have Autoimmune Hepatitis (AIH) should be advised not to get pregnant if they have cirrhosis, especially if their MELD score (a system used to measure the severity of chronic liver disease) is greater than 10. This is mainly because of the risk of bleeding in the gastroesophageal varices (enlarged veins in the esophagus). However, other related risks include ascites (abnormal buildup of fluid in the abdomen), spontaneous bacterial peritonitis (an infection of the fluid in the abdomen), hepatic encephalopathy (brain disorder associated with liver disease), and hepatorenal syndrome (progressive kidney failure).
Preventing Autoimmune Hepatitis and Pregnancy
It’s crucial for women with autoimmune hepatitis (AIH) to understand that their condition could lead to complications for their unborn child, including premature birth and death. Therefore, it’s recommended for these women to postpone pregnancy until their AIH has been reasonably under control for at least a year. Getting top-notch prenatal and antenatal care can go a long way, as well as closely coordinating with a specialist familiar with AIH management during and after pregnancy. Under the close supervision of healthcare providers, these women should continue taking their medications and schedule regular visits to the doctor.
It’s also important to note the impact of lifestyle on the management of AIH. Eating a balanced and nutritious diet while avoiding obesity is highly recommended as obesity can contribute to fatty liver disease, which may exacerbate AIH. Avoiding all kinds of alcohol, including beer, wine, and liquor is also crucial as they can lead to fatty liver and cause more damage to the liver. Also, some herbs can inflict serious damage to the liver and may even trigger AIH. Therefore, patients are advised against seeking herbal treatments for their liver issues.